Can GPs Gut Instinct Diagnose Cancer Earlier?

Learning from the Rapid Diagnostic Centre

Bethan Stephens

Background

• Wales lowest cancer survival rates in Europe

• Cwm Taf lowest survival rates in Wales

• Number of cancers diagnosed on Non-USC pathway outnumbers USC diagnoses

• Danish cancer pathway 16.2% detection rate – GPs gut instinct was common reason for referral and had strong predictive value

• WG funded two pilot pathways

Service Overview

• The Rapid Diagnostic Service commenced in the Royal Glamorgan Hospital on 18th

July 2017

• 2 sessions a week (Tuesday afternoon and Thursday morning)

• The service commenced with the Cynon cluster before extending to Merthyr (25th

Sept 17), Taf Ely (1st Dec 17) and Rhondda (1st Feb 2018).

• The Rapid Diagnostic Service team comprises of:• 2 part-time Pathway Coordinators

• 1 part-time HCA

• 3 acute physicians (operating on a rota basis)

• 4 radiologists (operating on a rota basis)

• 3 GPs (operating on a rota basis)

Day 1 Within 7 days

Patient presents to primary care with non-

specific symptoms

Concern of underlying malignancy but not indicative of tumour

site

Rapid Diagnostic Pathway

Day 2

Patient discussed by MPT - initial investigation results available

Patient attends non-specific symptom clinic (2 per week) run by MPT for

further investigation / clinical assessment

Non-cancer related

diagnosis

Suspicion of site specific

cancer

Within 14 days

Further investigations undertaken

Referral to relevant specialty

USC Pathway initiated

Discharge to GP with advice

Referral to appropriate

specialty

Within 21 days

Patient discussed by MPT. All

investigation results available

Onward referral to appropriate

specialty

GP maintains clinical responsibility for the patient Clinical responsibility transfers to multi-professional team

No diagnosis –additional

investigations requested

GP informs patient they suspect a possibility of cancer and referral will

be made to the non-specific symptom MPT.

Patient provided with information leaflet and

Coordinator contact details

GP requests suite of blood tests and chest X-Ray to be available for

MPT to review and makes electronic referral to Rapid

Diagnostic Service

Referral received by Rapid Diagnostic Service

Presenting Complaint

Symptom % of patients referred with this

symptom

Weight loss 76%

Fatigue 26%

Anaemia 9%

Nausea 10%

Lack of appetite 19%

Abdominal pain 13%

Shortness of breath 5%

Patient Vague Symptom Experience

• How long from when you first experienced your symptoms until you saw your GP?

Less than 1 week 12%

Less than 1 month 32%

1 to 3 months 28%

4 to 6 months 8%

More than 6 months 15%

Don’t know 5%

• How many times did you see you GP before you were referred to the rapid diagnostic clinic?

Once 28%

Twice 19%

3 or 4 times 33%

5 or more times 18%

Don’t know 2%

Clinic activity

• Total number of referrals: 1029

• Total number of patients seen: 739 (new appt)

• Number of clinic sessions: 158

• Appointments declined by patient: 6

• Number of inappropriate/redirected referrals: 20

• Number of patients admitted to secondary care prior to RDC appointment: 14

• Number of deceased: 3

• Number of DNAs: 13

Clinic Outcomes

A1 – Referral to MDT 75

A2 – Further Investigations 101

B1 – Referral to Sec Care 173

B2 – Referral to GP 91

C1 – Referral to Sec Care 92

C2 – Referral to GP 207

Non-cancer outcomes include:

• Chronic kidney disease

• Interstitial lung disease

• Hyperthyroidism

• COPD

• Diverticular disease

• Anaemia

• Liver cirrhosis

• Diabetes

• Pancreatitis

• Anxiety

Further investigations

(to rule out cancer) include:

• Endoscopy

• Colonoscopy

• Trucut biopsy

• Ultrasound

• CT Head

• MCRP

• MRI

• PET scan

Case Studies

Patient A

• 67 year old male with 4 month history of painful micturition, groin pain and constipation

• 2 stone weight loss

• Treated for UTI’s – 3 courses of antibiotics

• GP arranged PSA and ultrasound both of which were normal

• Seen in Rapid Diagnostic Clinic – normal clinical examination

• CT TAP showed metastatic prostate carcinoma with lung metastasis / second lung primary

Patient B

• 36 year old lady with 5 month history of nausea and loss of appetite

• 7 stone weight loss

• Long history of mental health issues and alcohol dependence

• Treated for anxiety disorder

• 5 GP consultations with these symptoms

• CT showed diffuse peritoneal disease, mesenteric mass with free fluid in the pelvis

• Referred to Gynaecology MDT - biopsies showed squamous cell carcinoma of the cervix

• Referred to Velindre for chemotherapy / radiotherapy

Patient C

• 58 year old lady with 5 month history of back pain and intermittent abdominal pain

• 4 GP consultations with these symptoms

• Lumbar X-ray and blood tests normal

• CT showed multiple enlarged abdominal lymph nodes consistent with Lymphoma

• Referred to Haematology MDT

Patient Comments

“It is reassuring to have

such a rapid service at a

worrying time. I sincerely

hope that the service is

able to continue beyond

the pilot”

“Absolutely first

class treatment

from beginning to

end”

“I felt I was treated really well,

and love the fact I had the

results straight away with no

worry waiting for appointments.

Well done to you all”

“I walked in

thinking the worst,

but came out

feeling reassured”“I found everyone I met and talked to

were very kind, considerate and did a

great job”“Exemplary treatment

from all staff –

wonderful”

HistoryPotential GP visits saved Potential Hospital referrals saved

83 year old female, Wt loss CT TAP - NAD, poor diet identified as an issue, referred to dietician x1-2 x2 gastro35 year old male, significant weight loss, CT TAP _NAD, Alcohol XS identified as cause. Offered CDAT referral , declined, Informed Alcohol intake excessive, started on Thiamine x1-2 x1 referral to gastro x1 gastro follow up65 year old female, Weight loss, CT TAP - NAD, weight loss secondary to emphysema. Inhalers changed smoking cessation referral made and NRT started x1-2 x1 referral to gastro x1 gastro follow up61 year old man, wt loss, CT TAP - NAD, started on anti depressants x1-2 x1 referral to gastro x1 gastro follow up47 year old man, wt loss - CT TAP NAD, poor diabetic control , referred on to DM Nurses x1-2 x1 referral to gastro x1 gastro follow up46 year old CT TAP- Radiological lung cancer , incurable - informed of diagnosis, liver biopsy arranged, on day of biopsy, deteriorated and admitted and died on 3/2/18. Seeing in RDC gave the patient and wife, a week to come to terms with condition and possiblyprepare for the death. x2 N/A

78 yr old CT TAP - radiological pancreatic cancer. Informed of diagnosis, put on next upper GI MDT and met upper GI cancer CNS x1Possibly x1 surgical referral whilst waiting for CT

Abdo

80 yr old male CT TAP - Incidental finding of isolated lung lesion. Patient informed, PET requested and referred to lung MDT x1-2 x2 -3 , gastro and then referral on to chest

81 yr old male. Wt loss, CT TAP- NAD, depression picked up and started on antidepressants and referred to dietician x2-3 x1 referral to gastro x1 gastro follow up

84 year old, wt loss , CT TAP - no malignancy, some bronchiectasis, referred to dietician , Physio and pulmonary rehab X2 x1 referral to gastro x1 gastro follow up75 year old female wt loss, CT TAP - NAD, referred to Rheum to confirm PMR diagnosis, ECHO, PFT's, 6MWT requested and for respiratory follow up x3 x2 -3 gastro and then Resp +/- cardio

90 year old , wt loss, CT TAP - resectable lung cancer. Told of diagnosis, met Lung cancer CNS, PET requested, referred to Resp X2 x1 referral to gastro x1 gastro follow up80 year old , wt loss, CT TAP - NAD. Diagnosis made of age related decline, early dementia. Referrals made to at home service, memory clinic and palliative care. DNAR discussed and decision documented in clinic. Seen by at home team on 9/1/18 . Patient died on 12/1/18 * x2-3 x3 and likley admission for death

80 year old female. Known pulmonary fibrosis. CT colon requested as OPD. No imaging on day required. x1 x1 referral to gastro x1 gastro follow up

81 year old female. Weight loss. CT TAP - NAD. Likely early dementia. Referred to memory clinic and at home service x2 x1 referral to gastro x1 gastro follow up68 year old female. Wt loss. CT TAP infective change . RMZ and adrenal opacity. Given antibiotics, repeat CT Chest and MRI adrenals requested and Referred to lung MDT x1 x2 gastro and x1 extra resp

73 year old female. Wt loss. CT TAP - NAD. Depression and prolonged bereavement diagnosed. Started on antidepressants x3 x1 referral to gastro x1 gastro follow up47 year old female. Wt loss. CT TAP - emphysema. Smoking cessation advice given and prescribed NRT and inhalers . Also referred to gastro as 'mural thickening of small bowel' and OGD requested x3

x3 gastro (initial assessment, referral to Resp for Emphysema, waiting for scan reports)

88 year old female . Wt loss. CT TAP - NAD. Age related decline and fragility. Referred to at home service x3 x1 referral to gastro x1 gastro follow up

GP/Secondary care referrals saved (sample of 19 patients)

Conclusions

• Trust our instincts 6.4% diagnosis rate

• RDC well received amongst patients and GPs

• Need patients to present early